Companies Revise Course of Guides and Open Portal for Shock Billing Impartial Dispute Decision

The DOL, IRS, and HHS have collectively issued revised course of guides for impartial dispute decision (IDR) underneath the No Surprises Act, enacted as a part of the Consolidated Appropriations Act, 2021 (CAA) (see our Checkpoint article). As background, the CAA expanded affected person protections to protect people from shock payments for sure out-of-network emergency and non-emergency providers, and the IRS, DOL, and HHS collectively issued interim closing rules in two components to implement the legislation. Half I addresses participant cost-sharing for providers topic to the CAA, in most conditions utilizing the qualifying cost quantity (QPA), which relies on the plan’s median in-network fee (see our Checkpoint article). Half II explains the position of licensed IDR entities (IDREs), together with charges, timing, and elements IDREs might contemplate in choosing a celebration’s cost quantity (see our Checkpoint article). In response to a problem by suppliers, a federal trial court docket invalidated a portion of the Half II rules that prioritized the QPA over different elements in figuring out the out-of-network fee. The companies then issued a memorandum indicating that they might replace their steerage paperwork to adapt with the court docket’s order (see our Checkpoint article).

Beforehand issued IDR course of guides (see our Checkpoint article) have now been revised with modifications to tables and explanations that deal with the court docket’s willpower that the CAA requires IDREs to contemplate—along with the QPA—credible data related to 5 different circumstances (resembling a supplier’s coaching, expertise, and outcomes; the supplier’s market share; and the affected person’s “acuity” or the complexity of offering providers to the affected person) and different related data submitted by both occasion. Notably, the revised steerage has deleted references to a presumption in favor of the QPA as the suitable out-of-network fee. Nevertheless, the steerage distinguishes between air ambulance and different providers. For non-air ambulance providers, the steerage gives that the IDRE should contemplate the QPA plus credible data on the 5 different circumstances recognized within the CAA. For air ambulance providers, the steerage notes that the IDRE ought to contemplate credible data aside from the QPA “to the extent that” the knowledge clearly demonstrates that the QPA is materially completely different from the suitable out-of-network fee for the certified air ambulance service. Further steerage can be supplied on the quantity, timing, and assortment of IDRE and administrative charges, together with steerage for batched claims and bundled cost. And a set of basic shock billing FAQs for suppliers was launched with, amongst different issues, additional steerage on charges.

EBIA Remark: The differentiation between air ambulance and different providers displays the scope of the court docket’s ruling on the Half II rules. As a result of the problem was introduced by well being care suppliers, the court docket’s ruling didn’t deal with the rules relevant to air ambulance providers and, underneath the method steerage, the QPA retains heightened significance in figuring out the out-of-network fee for air ambulance providers. The federal IDR Portal is now reside, so plans and insurers will need to familiarize themselves with these reworked course of guides since some timeframes for motion are fairly brief. Needless to say additional modifications could also be forthcoming, and litigation by suppliers might necessitate different modifications to the method. For extra data, see EBIA’s Well being Care Reform guide at Part XII.B.3 (“Shock Medical Billing: (Emergency and Non-Emergency Companies”). See additionally EBIA’s Group Well being Plan Mandates guide at Part XIII.B (“Affected person Protections”) and EBIA’s Self-Insured Well being Plans guide at Part XIII.C (“Federally Mandated Advantages”). And don’t miss our upcoming webinar, “Shock Billing Protections Beneath the No Surprises Act: What Group Well being Plans Ought to Know” (reside on 5/11/2022).

Contributing Editors: EBIA Employees.